NHS England and NHS Improvement

Starting Well Core: 0-2s dental access and prevention framework

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Starting Well Core: 0-2s dental access and prevention framework

Publishing approval number: 000079 Version number: 1.0 First published: September 2019 Prepared by: OCDO

This information can be made available in alternative formats, such as easy read or large print. Please contact the Starting Well Core Project Team at england.ocdo-pm-smile4life@nhs.net

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Contents Starting Well Core: 0-2s dental access and prevention framework ........................... 2

Contents.............................................................................................................. 3

1 Equality and health inequalities statement ....................................................... 5

2 Overview of initiative ...................................................................................... 6

2.1 Background ............................................................................................. 6

2.2 Aims and objectives ................................................................................. 7

2.3 How will it work? ...................................................................................... 7

2.3.1 Capacity............................................................................................ 7

2.3.2 Incentive and remuneration ................................................................ 7

2.3.3 Submission of claims ......................................................................... 7

2.3.4 Funding............................................................................................. 8

2.3.5 Implementation .................................................................................. 8

2.4 Expected outcomes and benefits .............................................................. 8

2.5 Alignment with other children’s oral health initiatives .................................. 9

2.5.1 NHS England Starting Well: a SMILE4LIFE initiative ............................ 9

2.5.2 Dental Check by One, BSPD .............................................................. 9

2.5.3 Children’s Oral Health Improvement Programme Board, PHE ............... 9

3 Interventions ............................................................................................... 10

3.1 Practice based preventive care ............................................................... 10

3.2 Safeguarding ......................................................................................... 10

3.3 Equality and health inequalities duties ..................................................... 11

4 Payment mechanism and funding ................................................................. 12

4.1 Payment mechanism.............................................................................. 12

4.1.1 GDS & PDS Statement of Financial Entitlement – application to Starting Well Core.................................................................................................... 12

4.2 Funding ................................................................................................. 13

4.2.1 Funding options ............................................................................... 13

4.2.2 Securing funds ................................................................................ 13

5 Practice participation ................................................................................... 15

5.1 Implementation approach ....................................................................... 15

5.2 Mitigating risk ........................................................................................ 15

5.3 Securing providers ................................................................................. 16

6 Training and resources ................................................................................ 18

6.1 Training event resources ........................................................................ 18

6.2 Resource packs for professionals ........................................................... 19

7 Communications and engagement ............................................................... 20

7.1 NHS England......................................................................................... 20

7.2 Local and regional communications teams............................................... 20

7.3 NHS primary care dental providers.......................................................... 20

7.4 Professional stakeholders....................................................................... 20

7.5 Patients and the public ........................................................................... 21

8 Monitoring and evaluation ............................................................................ 22

8.1 Support to implementation ...................................................................... 22

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8.2 Evaluation ............................................................................................. 22

9 Appendices ................................................................................................. 23

9.1 Draft template business case .................................................................. 23

9.2 Draft letter from commissioner to provider ............................................... 30

9.3 Communications and engagement activities ............................................ 32

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1 Equality and health inequalities statement Promoting equality and addressing health inequalities are at the heart of NHS England’s values. Throughout the development of the policies and processes cited in this document, we have:

• Given due regard to the need to eliminate discrimination, harassment and victimisation, to advance equality of opportunity, and to foster good relations between people who share a relevant protected characteristic (as cited under the Equality Act 2010) and those who do not share it; and

• Given regard to the need to reduce inequalities between patients in access to,

and outcomes from healthcare services and to ensure services are provided in an integrated way where this might reduce health inequalities.

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2 Overview of initiative

2.1 Background

Despite being largely preventable, tooth decay remains a significant health problem amongst young children in England. Public Health England (PHE) data shows almost a quarter of 5-year olds1 and 12% of 3-year olds2 have experienced tooth decay, and alongside the risks of pain and infection, this can have a wider impact on children’s nutrition, school-readiness, development and well-being. Furthermore, tooth decay is the leading cause of hospital admission for children aged 5-9 years, contributing to an NHS spend on hospital-based tooth extractions for children in excess of £35m per year. Low dental access rates for young children may be a contributing factor to the poor state of child oral health. Currently only 13% of children under 2 years of age are visiting a NHS dentist each year, 3

however there is evidence to support the requirement for young children’s dental visits, for oral and systemic health reasons.4 Moreover, evidence suggests that the average dental related costs may be less for children who received earlier preventive care.5 Recommendations of the major professional associations6 converge to a child’s first dental visit taking place early, at the time of the first tooth eruption (around age 6 months) or by age 1 year. 7 In alignment with this, the British Society of Paediatric Dentistry has been leading the Dental Check by One campaign, calling for children’s first dental checks to be carried out before their first birthdays.8 Against this context, the Starting Well Core offer has been developed for local commissioners, with a view to advancing equality of access for children aged 0-2 years, reducing the health inequalities faced by young children, and supporting the provision of a first dental check by one at a national level. The 2019 NHS Long Term Plan9 has identified Starting Well Core as a model of care which supports children’s health development as part of a strong start in life.

1 Oral health survey of 5-year-old children 2017, Public Health England 2 Oral health survey of 3-year-old children 2013, Public Health England 3 NHS dental statistics for England 2017/18, NHS Digital 4 Lee et al., 2006 5 Savage et al., 2004 6 American Academy of Paediatric Dentistry, European Academy of Paediatric Dentistry, American Dental Association, Canadian Dental Association, Australian Dental Association, American Academy of Paediatrics, British Society of Paediatric Dentistry and Royal College of Surgeon’s England – Faculty of Dental Surgery. 7 European Academy of Paediatric Dentistry. Guidelines on Prevention of Early Childhood Caries: An EAPD

Policy Document. 2008; American Academy of Pediatric Dentistry. Perinatal and Infant Oral Health Care. 2016. 8 http://bspd.co.uk/For-Patients/Dental-Check-by-One 9 https://www.longtermplan.nhs.uk/

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2.2 Aims and objectives

Starting Well Core is a commissioning approach designed to promote dental access and preventive care for children aged 0-2 years. Earlier access to evidence-based preventive interventions supports efforts to reduce the proportion of young children requiring hospital tooth extractions due to dental decay. The initiative aims to reduce health inequalities and improve oral health for children aged 0-2 years. The objectives of the initiative include:

• Increasing dental access and attendance for children aged 0-2 years;

• Promoting delivery of evidence-based preventive care in practice, including interventions such as oral health and dietary advice, support for oral health behaviour change, and fluoride interventions;

• Raising public and professional awareness to promote the timely attendance of children aged 0-2 years; and

• Providing NHS England dental commissioners with a method of commissioning

the offer within the existing dental contract.

2.3 How will it work?

In recognition of NHS England’s statutory duties around equality and health inequalities, Starting Well Core will encourage and enable NHS England contracted dental practices to accept additional child patients aged 0-2 years, and deliver early years preventive care and oral health advice. 2.3.1 Capacity

Starting Well Core dental practices will have sufficient freedom to fully utilise and potentially exceed commissioned capacity to provide dental checks with preventive care for children aged 0-2 years where local commissioners have available financial capacity to support the scheme. Once agreed with local commissioners, the initiative removes perceived financial barriers and encourages dental practices to fully utilise access opportunities for the acceptance of additional “new” child patients into the practice within existing contracts. 2.3.2 Incentive and remuneration

Practices participating in Starting Well Core will be able to deliver Units of Dental Activity (UDAs) in excess of 102% of their contract value, up to a maximum of 104%, attributable to eligible children aged 0-2 years (<24 months). 2.3.3 Submission of claims

In September 2017 the Chief Dental Officer England issued a notification for the avoidance of doubt pertaining to dental visits for children under 3 years of age. This

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provides clarity around the care to be delivered to ‘pre-cooperative’ children, and the corresponding documentation required, in order that dentists may submit claims and be appropriately remunerated. 2.3.4 Funding

It is recommended that dental commissioning teams who intend to implement the initiative consider securing anticipated local dental underspend to fund the initiative, taking account of other competing priorities, although the source of any funding made available for this initiative will ultimately need to be decided locally. 2.3.5 Implementation

The Starting Well Core offer is available for use locally by all dental commissioning teams from 1st April 2018. All NHS primary care general dental practices with existing NHS GDS contracts or PDS Agreements for mandatory dental services, in areas where NHS England has decided to commission the initiative, will be eligible for inclusion. Local decision making based on local population needs will determine the implementation approach. The Office of Chief Dental Officer, England, will develop and co-ordinate public and professional awareness activities, to promote the timely dental attendance of children aged 0-2 years at the national level. These should be complemented by other local communications and engagement activities, as deemed appropriate locally.

2.4 Expected outcomes and benefits

The expected outcome of Starting Well Core is a change in local commissioning that fully utilises access opportunities for children into practices. In the short term it is expected this will lead to an increase in dental access and the promotion of preventive care for children aged 0-2 years. In the longer term it is expected implementation will support the realisation of the following benefits:

• An increase in dental access and attendance for children aged 0-2 years;

• A reduction in hospital-based tooth extraction for children, with associated economic benefits;

• A reduction in restorative and emergency dental treatment for children attending NHS primary care dental services, with associated economic benefits;

• A reduction in Emergency Department attendances, a decrease in NHS 111

use and unscheduled dental care appointments, and a decrease in antibiotic and analgesia prescribing - for young children, with associated economic benefits; and

• A decrease in the number of missed school days associated with poor oral health, and a decrease in the number of days taken off work by parents or carers due to caring for children with poor oral health.

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2.5 Alignment with other children’s oral health initiatives

2.5.1 NHS England Starting Well: a SMILE4LIFE initiative

Starting Well: a SMILE4LIFE initiative is a NHS England programme of dental practice-based initiatives, which aims to reduce oral health inequalities and improve oral health in children under the age of 5. It involves patient and practice level interventions alongside work to strengthen relationships with local communities. The programme is commissioned across 13 high priority areas where children are deemed to have the greatest need for oral health improvement. By comparison, Starting Well Core is a complementary offer, available for use by all local NHS area teams, with a focus on children aged 0-2 years. 2.5.2 Dental Check by One, BSPD

Dental Check by One is a campaign led by the British Society of Paediatric Dentistry, which calls for children’s first dental checks to be carried out before their first birthdays. Starting Well Core supports and facilitates the provision of ‘Dental Check by One’, by promoting access for children aged 0-2 years. 2.5.3 Children’s Oral Health Improvement Programme Board, PHE

Improving the oral health of young children in England is a PHE priority. The Starting Well Core initiative aligns with the work of the PHE-led Children’s Oral Health Improvement Programme Board, whose ambition is that “every child grows up free from tooth decay as part of every child having the best start in life”.

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3 Interventions The following section outlines some of the key aspects of care that are expected to be delivered during dental visits for young children, in order to promote health and wellbeing and Make Every Contact Count.10 This does not represent an additional expectation of dentists or the dental team. The Note for the Avoidance of Doubt, issued in September 2017, provides further clarity around dental visits for ‘pre-cooperative’ children under 3 years, including examination, preventive advice, recall and details of who can undertake dental assessments in the dental team.

3.1 Practice based preventive care

The dental team should deliver preventive advice and interventions in line with Delivering Better Oral Health, 11 and where necessary support children and their parents or carers to change their health-related behaviours. This feeds into the Making Every Contact Count approach,6 whereby all interactions with children and families can be used as opportunities to encourage long-term behaviour change. Preventive care should be tailored to each individual child, and based on an oral health assessment which includes assessment of caries risk. As part of a dental check, each child should be assigned a risk based recall interval, in accordance with NICE recall guidelines - Dental checks: intervals between oral health reviews.12

3.2 Safeguarding

Dental teams have a statutory duty to protect children and adults who are at risk of abuse and neglect. Therefore, as detailed in extant policy, regulations and GDC Standards:

• Dental practices must have safeguarding policies and procedures in place,

which align with local multi-agency policies and procedures.

• Dental teams should undertake and record safeguarding training as appropriate.

• Dental teams should share relevant safeguarding information at an early stage with the appropriate agencies and professionals.

An overview of safeguarding is found in PHE’s Safeguarding in general dental practice: a toolkit for dental teams.13

10 https://www.gov.uk/government/publications/making-every-contact-count-mecc-practical-resources 11 https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-

prevention 12 https://www.nice.org.uk/guidance/cg19 13 https://www.gov.uk/government/publications/safeguarding-in-general-dental-practice

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3.3 Equality and health inequalities duties

In line with NHS England’s equality and health inequalities duties, it is expected that as part of wider local work to commission dental services based on local population needs, appropriate consideration is given to the local health inequalities landscape. This includes children who may be less likely to access dental services (e.g. Looked After Children, children with disabilities or with a parent/carer who is disabled, children from families where English is a second language, children with additional medical needs). Similarly, there should be appropriate mitigating action at the commissioning and dental service levels to address access barriers and reduce health inequalities (e.g. disabled access, reasonable adjustments in the dental practice environment, access to interpreting services, clinical pathways and/or referral pathways to support patients with additional or complex care needs).

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4 Payment mechanism and funding

4.1 Payment mechanism

Practices participating in Starting Well Core may be remunerated for Units of Dental Activity (UDAs) in excess of 102% of their contract value, up to a maximum of 104%, attributable to eligible children aged 0-2 years (<24 months). This is allowable under the Statement of Financial Entitlement (SFE).14 Once the local commissioning team has agreed the terms of the Starting Well Core payment mechanism with a participating dental practice, the practice provides care as commissioned throughout the year. The practice is responsible for the recruitment of eligible children and the delivery of prevention. There is no change to the monthly remuneration and claim submission process. Any additional activity is accounted for as part of end of year reconciliation. The local commissioning team may wish to notify the NHS BSA of the provider intent to claim for UDAs in excess of 102%, up to a maximum of 104%, attributable to eligible children. Please note that implementing Starting Well Core does not preclude innovative commissioning, the use of contract variations, nor the implementation of other local initiatives to support the delivery of dental care for young children outside this framework. 4.1.1 GDS & PDS Statement of Financial Entitlement – application to Starting

Well Core

Under usual circumstances practices can deliver up to 2% extra UDA activity in year, in addition to their negotiated annual contract value (NACV), which can either be carried forward or paid, subject to the discretion of the local commissioner.

As allowed under the SFE, subject to prior agreement with the commissioner for participating in a local oral health initiative (in this case Starting Well Core), practices can deliver up to 2% extra UDA activity in year, in addition to the existing 2%, so a maximum of 104% of their negotiated annual contract value (NACV). This can either be paid or carried forward, subject to the discretion of the local commissioner. To demonstrate agreement that this extra UDA activity is permitted, a letter of support or similar documented evidence from the local commissioner is required to confirm practice participation in the local oral health initiative, in this case Starting Well Core (see Section 5.3 Securing providers). Given that Starting Well Core looks to increase access for children aged 0-2 years, wherever possible additional in-year activity will be paid for at year end in order to maintain increased capacity and access opportunities. If activity is carried forward this will reduce capacity in the following year which may consequently decrease access opportunities.

14 Primary Dental Services Statements of Financial Entitlements (Amendment) Directions 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/765878/primary-dental-services-statements-of-financial-entitlements-amendments-directions_2018.pdf

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In line with arrangements set out in the SFE, Starting Well Core commissioning intentions must:

• Be a locality agreed priority;

• Reflect identified oral health needs as set out in local oral health plans and needs assessments;

• Be transparently commissioned and available to all practices which qualify under the criteria of the local scheme (see section 5.1); and

• Be available to GDS and PDS contractors with services hosted in the area

specified in the scheme criteria (see section 5.1).

4.2 Funding

It is recommended that dental commissioning teams who intend to participate in the scheme consider securing anticipated local dental underspend to fund the initiative, taking account of other competing priorities, although the source of any funding made available for this initiative will ultimately need to be decided locally 4.2.1 Funding options

There are likely to be two options for local teams to consider regarding resource allocation:

1. Securing dental underspend to support the initiative Local teams would agree to re-allocate a specific amount of funding from dental underspends back into primary dental care, to secure financial support at the local level.

2. Agreeing specified additional funds locally for the initiative (for example

funds no longer required elsewhere or previously unallocated funding) Local teams can look to secure funding from within their regional primary care allocation.

4.2.2 Securing funds

Consideration should be given to how Starting Well Core funding could be secured, with a view to deciding locally whether the initiative will become business as usual. To secure funds, dental commissioners should follow NHS England’s standing financial instructions, and local governance and decision-making processes. To support local business case development, a draft business case template has been provided (Appendix 9.1). This may be amended as appropriate for the local area.

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Additionally, the NHS BSA has developed forecast reports for each local area, which demonstrate access rates for children aged 0-24 months in the financial year 2016/17, and the increase in UDAs required to achieve certain aspirational access rates. There is also an option to input a UDA relative “value”, in order to calculate forecasted costs to achieve those aspirational access rates. This can be used to support business case development and local decision making around initiative funding. Forecast reports have been sent to members of the Starting Well Core Project Board, who include representatives from each Region. Regional representatives will disseminate this information accordingly. For further information please contact the Starting Well Core Project Team at england.ocdo-pm-smile4life@nhs.net.

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5 Practice participation Local decision making will determine which localities will be involved in the implementation of Starting Well Core. This may be all localities across a whole commissioning area or targeted localities within a commissioning area, as detailed in section 5.1. Within these localities, all NHS primary care general dental practices with existing NHS GDS contracts or PDS Agreements for mandatory dental services will be eligible for inclusion. There should be secured commitment to include qualifying providers prior to implementation. Implementation timelines will be determined locally. Local commissioning teams will be responsible for ensuring that when securing providers as far as possible any risks are mitigated and that NHS England’s standing financial instructions are adhered to, through local governance and decision-making processes.

5.1 Implementation approach

Dental commissioners working with Local Dental Networks, Dental Public Health colleagues, and any other relevant stakeholders as deemed necessary, should establish an implementation approach. This may be an approach involving coverage of the whole commissioning area or targeted localities only. Where a targeted approach is adopted, an audit of evidence (e.g. needs assessment) will be required to justify why a specific locality or localities have been chosen. It is recommended that as part of local decision making around the implementation approach, consideration is given to the following:

• The findings of local needs assessments around child oral health;

• Prioritising localities in areas of greater social deprivation, where needs are

likely to be greatest;

• Prioritising localities with low access rates for children aged 0-2 years;

• Prioritising localities with high referral rates for child hospital tooth extractions;

• Prioritising localities where it is challenging for services to meet the demand for

access; and

• Prioritising localities with greater oral health and access needs, where there are a number of practices which are under-delivering against contract targets.

5.2 Mitigating risk

The list below highlights risks that commissioning teams should consider in developing the implementation of the scheme locally.

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Risk to initiative delivery - The pool of resources locally may be limited and commissioning teams will need to consider which localities will be included in the initiative. Financial risk - Balancing other priorities at local level with the initiative. Whilst utilising the Statement of Financial Entitlements may be seen as an alternative to additional financial investment, there may already be a commitment to spend ‘claw-back’ and under delivery elsewhere in the healthcare economy. Commissioning arrangements should be considered alongside the bigger picture locally in order that additional financial pressures are not introduced into the healthcare system. Clinical risk - Ensuring patients’ oral health is improved and patient access and experience is not compromised is paramount. When securing providers, commissioning teams will need to ensure that any concerns about clinical and contractual performance have been addressed, and that the inclusion of a provider in the scheme does not introduce an additional burden to the practice that may ultimately lead to a performance issue. Conflicts with existing schemes - Commissioning teams will need to be mindful of any existing access initiatives or schemes specifically targeted at children. If such a scheme already exists locally, commissioners may wish to consider how this can be adapted to accommodate Starting Well Core objectives and outcome measures. Conversely, provided the main objectives and outcome measures are being met commissioners may wish to consider additional activities to enhance the scheme.

5.3 Securing providers

Dental Commissioners will be expected to communicate directly with providers in localities where Starting Well Core is being implemented, to provide the appropriate local information about the initiative and any guarantees around additional contractual tolerance and remuneration. A draft template letter has been provided which may be amended by Dental Commissioners as appropriate to send to providers (Appendix 9.2). When securing providers in areas of implementation, commissioning teams may wish to consider the following:

1. Commissioning teams should assure themselves that providers should not be currently under investigation for concerns relating to fraud or poor clinical performance either locally or by any of the national regulatory bodies.

2. In considering smaller NHS contracts (some of which may be located in larger

predominantly private practices) and ‘child-only contracts’, commissioning teams should assure themselves that the delivery of routine NHS services is maintained alongside Starting Well Core.

3. Providers will be making a commitment for the duration of the initiative, therefore

their contract, normally, should not have an end date prior to the end of the

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initiative. However, care must be taken to avoid creating any potential financial pressure in future years.

4. Practices should be able to demonstrate that they are presently taking on

children and that they are able to provide preventive care to children aged 0-2 years.

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6 Training and resources It is recognised that the profession may require support pertaining to preventive dental care for young children, in preparation for Starting Well Core implementation. Training event resources and resource packs for professionals have been developed centrally. These have been made available for local use and circulation by Local Dental Networks and NHS England commissioning teams.

6.1 Training event resources

Local commissioners, working with Local Dental Networks, Dental Public Health colleagues, Local Authorities and other local stakeholders, such as Paediatric Managed Clinical Networks, may wish to organise or present at a local event(s) to inform dental teams and wider stakeholders (e.g. Health and Social Care professionals and the Early Years workforce) of Starting Well Core, and provide training for dental professionals. A range of template training materials have been developed by the Office of Chief Dental Officer, England, to support local training or communication events. They have been designed to support and increase the confidence of dental teams when caring for young children, and to enhance the clinical knowledge and skills of dental professionals. They include:

• Template Starting Well Core Training Event presentation, covering the following areas:

o Section 1: Starting Well Core – an overview

o Section 2: The evidence base for preventive care

o Section 3: Caring for infants and pre-school children: practical clinical tips and advice to promote oral health

• Corresponding template Continuing Professional Development (CPD)

materials, including:

o Agenda

o Evaluation form

o CPD certificate As the resources are templates for local use, they may be adapted and edited as appropriate. It is recommended that those using the resources ensure they comply with local communications and branding guidance. These training event resources were made available to LDNs in March 2018. For further information please contact the Starting Well Core Project Team at england.ocdo-pm-smile4life@nhs.net.

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6.2 Resource packs for professionals

The following sets of online resources have been developed by the Office of Chief Dental Officer, England:

1. Starting Well Core Resource Pack for Dental Professionals – consisting of

resources designed to support dental professionals caring for young children

aged 0-2 years.

2. Starting Well Core Resource Pack for Health & Social Care and Early Years

Professionals – consisting of resources designed to support oral health

promotion for the 0-2 year age group in non-dental settings.

They include a range of professional- and public-facing resources (e.g. learning resources and guidance for professionals, posters for health care and early years settings, leaflets for the public) from a variety of sources which can be freely downloaded. Localised versions of these resource packs were made available to LDNs and dental commissioning teams in June 2018 for local dissemination as appropriate. Resources can also be downloaded via the following link: https://www.bspd.co.uk/Resources/Related-Links. For further information please contact the Starting Well Core Project Team at england.ocdo-pm-smile4life@nhs.net.

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7 Communications and engagement The Office of Chief Dental Officer, England, will develop and co-ordinate public and professional awareness activities, to promote the timely dental attendance of children aged 0-2 years at the national level. These should be complemented by local communications and engagement activities, as deemed appropriate locally. Activities will be undertaken with a focus on reaching children who may be considered high-risk or vulnerable, their parents and carers, and marginalised communities. This includes targeting Health and Social Care or Early Years professionals who may be more likely to make contact with higher-needs groups.

7.1 NHS England

A draft template slide set for use by local commissioning teams who wish to share information about Starting Well Core at local staff briefings is available on request. Please contact the Starting Well Core Project Team at england.ocdo-pm-smile4life@nhs.net.

7.2 Local and regional communications teams

Commissioners, working with local and regional communications teams, may wish to consider any necessary or useful internal and external communications activities in relation to local implementation of Starting Well Core. They may also need to consider lines to take with regards to the local implementation approach, for example if any questions are posed around why the initiative is not being implemented in certain localities, or why some practices have more capacity to see children aged 0-2 years.

7.3 NHS primary care dental providers

As described in section 5.3, Dental Commissioners are asked to communicate directly with participating providers in their localities to provide the appropriate information about Starting Well Core A draft template letter has been provided which can be amended as appropriate to support communication to providers (Appendix 9.2). Further examples of suggested activities for communications and engagement are at Appendix 9.3.

7.4 Professional stakeholders

Dental Commissioners, working with Local Dental Network Chairs, Dental Public Health colleagues, and other local stakeholders as necessary, may wish to undertake communication and engagement activities with professionals from across the Health and Social Care and Early Years workforce (e.g. health visitors, GPs, children’s centres). This may promote early-years dental access through raising awareness, and encouraging signposting and dental referrals. Consideration should be given to

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reaching those professionals who are most likely to make contact with high-risk or vulnerable children, to align with efforts to reduce health inequalities. A sample of suggested activities for communications and engagement is at Appendix 9.3.

7.5 Patients and the public

Dental Commissioners, working with Local Dental Network Chairs, Dental Public Health colleagues, and other local stakeholders as necessary, may wish to undertake communication and engagement activities with patients and the public, in order to promote timely and regular early-years dental attendance. Consideration should be given to reaching high-risk or vulnerable children, to align with efforts to reduce health inequalities. Consideration should also be given to population health literacy. A sample of suggested activities for communications and engagement is at Appendix 9.3.

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8 Monitoring and evaluation

8.1 Support to implementation

The progress of Starting Well Core implementation will be monitored at the commissioning level. The Starting Well Core project team will contact Dental Leads as appropriate for information regarding local implementation approach, the number of participating practices and any other local activities (e.g. training events).

8.2 Evaluation

Evaluation of Starting Well Core and progress towards strategic objectives will be led centrally. This will include monitoring data relating to the following:

• Dental access for children;

• Child oral health;

• Delivery of preventive interventions;

• Type of dental treatment received by children, including hospital-based dental

extractions; and

• Costs associated with children’s hospital-based dental extractions. It is expected that most data will be collected routinely via NHS BSA and Public Health England, however local dental commissioning teams may also be asked to provide information or collect data to support evaluation. Where required, further details will be issued to the relevant stakeholders by the lead for evaluation.

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9 Appendices

9.1 Draft template business case

This draft template business case is for local use. The content and structure may be amended as appropriate:

[Name of Board/Committee]

Agenda Item Ref:

Date of Meeting

Report Title Starting Well Core: implementation proposal

Author

Presented By

Actions/Decisions Required

1 Purpose

This paper:

1. Provides the current status of oral health and dental access for young children and the need to take action.

2. Outlines the proposal for the Starting Well Core initiative to be implemented in [locality/area].

3. Requests approval to commence implementation of Starting Well Core.

2 Background

Current status of children’s oral health Despite being largely preventable, tooth decay remains a significant health problem amongst young children in England. Public Health England data shows almost a quarter of 5 year olds15 and 12% of 3 year olds16 have experienced tooth decay, and

15 Oral health survey of 5-year-old children 2017, Public Health England 16 Oral health survey of 3-year-old children 2013, Public Health England

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alongside the risks of pain and infection, this can have a wider impact on children’s nutrition, school-readiness, development and well-being. Furthermore tooth decay is the leading cause of hospital admission for children aged 5-9 years, contributing to a NHS spend on hospital-based tooth extractions for children in excess of £35m per year. There are also significant costs associated with unscheduled dental care appointments attendance at GP for dental pain and sepsis, inappropriate presentations at A&E and repeat prescriptions of antibiotics and analgesia. A significant proportion of the additional costs to NHS England are borne by CCG budgets.17 Low dental access rates for young children may be a contributing factor to the poor state of child oral health. Currently only 13% of children under 2 years of age are visiting a NHS dentist each year, 18 however there is evidence to support the requirement for young children’s dental visits, for oral and systemic health reasons. 19 Moreover, evidence suggests that the average dental related costs may be less for children who received earlier preventive care.20 [Insert local information on children’s oral health to describe local status, e.g. dmft data, dental access data.] Case for change Statutory duties NHS England has a legal duty as the single commissioner for dental services to ensure the NHS:

• Delivers better outcomes for dental patients, within its available resources, upholds and promotes the NHS Constitution and delivers the key objectives of the NHS Mandate. Mandate objectives include: Objective 1: Through better commissioning, improve local and national health outcomes, particularly by addressing poor outcomes and inequalities. Objective 4: To Lead a Step Change in the NHS in preventing Ill Health and Supporting People to Live Healthy Lives. Objective 6: To improve Out of Hospital care.

• Supports all relevant bodies in meeting their duties under the Equality Act

2012 and for reducing health inequalities under the NHS Act 2006 (as amended by the Health and Social Care Act 2012).

• Promotes innovation in the provision of healthcare services.

17 A sum approximately equal to one fifth of the NHS dental budget is spent on managing the consequences of dental disease (HSCIC, 2015). 18 NHS dental statistics for England 2017/18, NHS Digital 19 Lee et al., 2006 20 Savage et al., 2004

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• Obtains advice appropriate for enabling it effectively to discharge its functions from those with a broad range of professional expertise in the prevention of illness and the improvement of public health.

• Works through its national, regional and area teams to discharge these

responsibilities. NHS Long Term Plan The 2019 NHS Long Term Plan commits to delivering a strong start in life for children and young people, with a focus on prevention, reducing health inequalities and redesigning services. The LTP identifies Starting Well Core as a model of care which supports dentists to see more children at an earlier age, to help shape healthy dental habits early and prevent childhood tooth decay. This is part of supporting children’s overall health development. The Government There is a Conservative manifesto pledge to “… support NHS dentistry to improve coverage and reform contracts so that we pay for better outcomes, particularly for deprived children”. [Insert supportive local government and MP pledges where applicable.] Work of wider stakeholders

• In recognition of the poor state of children’s oral health and low dental access rates for young children, the British Society of Paediatric Dentistry is leading the Dental Check by One campaign, calling for all children to have their first dental check by their first birthday. 21

• Improving the oral health of young children in England is a PHE priority. They have set up a Children’s Oral Health Improvement Programme Board bringing together over 20 stakeholder organisations that all have key leadership roles for children and young people. The ambition of the Board is that “every child grows up free from tooth decay as part of every child having the best start in life”. An objective of the Board is to ensure that oral health is on everyone’s agenda.22

• In 2015 the Faculty of Dental Surgery at the Royal College of Surgeons

published the paper ‘The state of children’s oral health in England’,23 calling for the stakeholders to take greater measures to tackle tooth decay.

Local work and priorities

21 http://bspd.co.uk/Resources/Dental-Check-by-One 22 https://www.gov.uk/government/news/launch-of-the-childrens-oral-health-improvement-programme-board 23 http://www.rcseng.ac.uk/fds/policy/documents/fds-report-on-the-state-of-childrens-oral-health.

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[Insert details of local work and priorities, which align with and/or support local Starting Well Core implementation.] Against this context there is a requirement to advance equality of dental access for children aged 0-2 years and reduce the health inequalities faced by young children in [locality/area].

3 Proposal

In recognition of the need for change, the proposal is to implement Starting Well Core locally. Starting Well Core Aims and objectives Starting Well Core is a commissioning approach designed to promote dental access and preventive care for children aged 0-2 years. Earlier access to evidence-based preventive interventions supports efforts to reduce the proportion of young children requiring hospital tooth extractions due to dental decay. The initiative aims to reduce health inequalities and improve oral health for children aged 0-2 years. The objectives of the initiative include:

• Increasing dental access and attendance for children aged 0-2 years;

• Promoting delivery of evidence-based preventive care in practice, including interventions such as oral health and dietary advice, support for oral health behaviour change, and fluoride interventions; and

• Raising public and professional awareness to promote the timely attendance

of children aged 0-2 years.

How the initiative works Starting Well Core ensures that dental practices have sufficient freedom to fully utilise and potentially exceed commissioned capacity to deliver dental checks and preventive care to children aged 0-2 years. Practices participating in Starting Well Core will be remunerated for Units of Dental Activity (UDAs) in excess of 102% of their contract value, up to a maximum of 104%, attributable to eligible children aged 0-2 years (<24 months). The submission of claims is supported by the Notification for the Avoidance of Doubt pertaining to dental visits for children under 3 years of age (issued September 2017). This provides clarity around the care to be delivered to ‘pre-cooperative’ children,

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and the corresponding documentation required, in order that dentists may submit claims and be appropriately remunerated. The Office of Chief Dental Officer, England, will develop and co-ordinate public and professional awareness activities, to promote the timely dental attendance of children aged 0-2 years at the national level. [Where applicable, insert details around how these central activities may be complemented by local communications and engagement activities. For information to support the completion of this section please see document Starting Well Core: 0-2s dental access and prevention framework – section 7.] Local implementation approach [Insert details of local implementation approach, to be determined locally. Commissioners may also wish to add details around local training and communications/engagement activities where appropriate. For information to support the completion of this section please see document Starting Well Core: 0-2s dental access and prevention framework – sections 5,6 and 7.] Costs [Insert details of local implementation costs. To support this, data sets with financial forecasts have been made available locally. As well as potential remuneration costs, commissioners may wish to consider costs for training and communication/engagement activities where applicable. For information to support the completion of this section please see document Starting Well Core: 0-2s dental access and prevention framework – section 4.] Funding options [Insert details of local funding options, to be determined locally. For information to support the completion of this section please see document Starting Well Core: 0-2s dental access and prevention framework – section 4.] Recommendation for funding [Insert recommendation for funding, to be determined locally.] Expected outcomes and benefits The expected outcome of Starting Well Core is a change in local commissioning that fully utilises access opportunities for children into practices. In the short term it is expected this will lead to an increase in dental access and the promotion of preventive care for children aged 0-2 years. In the longer term it is expected implementation will support the realisation of the following benefits:

• An increase in dental access and attendance for children aged 0-2 years;

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• A reduction in hospital-based tooth extraction for children, with associated economic benefits;

• A reduction in restorative and emergency dental treatment for children

attending NHS primary care dental services, with associated economic benefits;

• A reduction in Emergency Department attendances, a decrease in NHS 111 use and unscheduled dental care appointments, and a decrease in antibiotic and analgesia prescribing - for young children, with associated economic benefits; and

• A decrease in the number of missed school days associated with poor oral health, and a decrease in the number of days taken off work by parents or carers due to caring for children with poor oral health.

Monitoring and evaluation Evaluation of Starting Well Core and progress towards strategic objectives will be led centrally by the Office of Chief Dental Officer, England. This will include monitoring data relating to the following:

• Dental access for children;

• Child oral health;

• Delivery of preventive interventions;

• Type of dental treatment received by children, including hospital-based dental

extractions; and

• Costs associated with children’s hospital-based dental extractions. Data will be collected via NHS BSA, PHE and local area teams.

4 Timescales

[Insert details of local timescales.]

5 Risks [The local risks of both accepting this proposal and choosing not to accept this proposal should be outlined, including the likelihood of and reasons for these risks. Risks relating to health and inequalities, finance and other local factors should be considered. It should be made clear how risks will be mitigated. For information to

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support the completion of this section please see document Starting Well Core: 0-2s dental access and prevention framework – section 4]

6 Actions for the Committee

It is recommended that the [Board/Committee] undertake the following actions:

• Agree for the Starting Well Core initiative to be taken forward locally, as per the proposal.

• Agree local funding for the Starting Well Core initiative.

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9.2 Draft letter from commissioner to provider

Draft template text for Dental Commissioners to use when contacting providers to confirm participation in Starting Well Core is provided below. This may be amended as appropriate locally:

[Address] [Date]

Dear [Provider] Re: Starting Well Core - implementation in [name of area] The Starting Well Core initiative is a commissioning approach designed to promote dental access and preventive care for children aged 0-2 years. The [name] commissioning team is implementing Starting Well Core in [area(s)]. This letter sets out how it will work locally and what this means for your practice. Additional capacity and remuneration Practices participating in Starting Well Core will be allowed to claim for Units of Dental Activity (UDAs) in excess of 102% of their contract value, up to a maximum of 104%, attributable to eligible children aged 0-2 years (<24 months). [Insert details and conditions of commitment/guarantee that commissioning team will grant this tolerance to provider, including any provider actions required.] There is no change to the remuneration and claim submission process for practices participating in Starting Well Core. Any additional activity under your contract attributable to children aged 0-2 years will be accounted for at year end using data provided by the BSA. To support the submission of claims, please refer to the notification for the avoidance of doubt pertaining to dental visits for children under 3 years of age at the following link. This provides clarity around the care to be delivered to ‘pre-cooperative’ children, and the corresponding documentation required, in order that dentists may submit claims and be appropriately remunerated: https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/09/letter-chief-dental-officer-visitsfor-children-under-3.pdf Resources

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[Insert details of any profession- or public- facing resources to support oral health promotion and preventive dental care for young children. This may include the Starting Well Core resource packs and other locally developed resources.] Local training [Insert details of any relevant local training regarding oral health promotion for young children] Local communications and engagement activities [Insert details of any relevant communications and engagement activities] For further information about Starting Well Core, please contact [contact details]. Yours sincerely, [NHS England Dental Commissioner details]

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9.3 Communications and engagement activities

The table below lists examples of communication and engagement activities to promote Starting Well Core and dental access for children aged 0-2 years. The examples are suggestions for consideration locally. Please note the list is not exhaustive and local teams may wish to undertake varying activity as deemed appropriate locally.

Stakeholder / setting

Suggested activities

Dental teams (including GDS, CDS, secondary care and specialist paediatric care)

Working with the Local Dental Network Chair, the local Paediatric Dentistry Managed Clinical Network, the Consultant in Dental Public Health and the local HEE Postgraduate Dental Dean: Share information about Starting Well Core and the Starting Well Core resource pack (see section 6.2) with dental teams in your locality. This may be part of local training or communication events. To support signposting, referrals and continuity of care between primary and secondary care dental teams, supply community and hospital dental services with a list of general dental practices who are participating in Starting Well Core and accepting new child patients. There may be opportunities for community and hospital dental teams to refer children or contact participating practices directly to support families/carers book appointments (e.g. via secure NHS.net email accounts).

Local Authorities Share the Starting Well Core resource pack (see section 6.2) with your Consultant in Dental Public Health. They will have links to the Health & Wellbeing Board, Public Health teams, Early Years teams and Social Care teams in the Local Authority. Working with the Consultant in Dental Public Health, select resources to circulate or distribute via the appropriate Local Authority teams, so they can be used or displayed by a wide range of settings and services (e.g. children’s centres, nurseries, social services, libraries, places of worship). Focus activity around children and families who may be considered high risk or vulnerable.

Health Visitors Health Visitors are likely to contact children and families who may be considered high risk or vulnerable. Working with Health Visiting leads: To support signposting and referrals, supply local Health Visiting services with a list of local dental practices who are participating

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Stakeholder / setting

Suggested activities

in Starting Well Core and accepting new child patients. There may be opportunities for Health Visitors to refer children or contact participating practices directly to support families/carers book appointments (e.g. via secure NHS.net email accounts). Promote a Dental Check by One and healthy dental behaviours, supported with resources from the Starting Well Core resource pack (see section 6.2). PHE have also produced an infographic to support Health Visitors with oral health promotion, as found at the following link: https://vivbennett.blog.gov.uk/wp-content/uploads/sites/90/2016/11/Improving-oral-health-for-children.pdf Produce stickers for the red book to prompt parents/carers to book their baby’s first dental check-up.

GPs Working with the relevant primary care networks, professional networks and CCGs: Email a poster(s) from the Starting Well Core resource pack (see section 6.2) to GP surgeries in your region, requesting they display it in their waiting rooms to promote a Dental Check by One. They may also be able to add the image to digital or social media feeds and profiles. To support signposting and referrals, supply local GPs with a list of local dental practices who are participating in Starting Well Core and accepting new child patients. There may be opportunities for GPs to refer children or contact participating practices directly to support families/carers book appointments (e.g. via secure NHS.net email accounts).

Community pharmacies

Working with NHS England Pharmacy Leads and Local Pharmacy Network Chairs: Email a poster(s) from the Starting Well Core resource pack (see section 6.2) to community pharmacies in your region, requesting they display it in their waiting rooms to promote a Dental Check by One. They may also be able to add the image to digital or social media feeds and profiles. To support signposting and referrals, supply local community pharmacies with a list of local dental practices who are participating in Starting Well Core and accepting new child patients. There may be opportunities for pharmacists to refer children or contact participating practices directly to support

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Stakeholder / setting

Suggested activities

families/carers book appointments (e.g. via secure NHS.net email accounts). Promote participation in the National Community Pharmacy Campaign from mid-May to mid-June 2019, which focusses on children’s oral health. Build on work and links developed during this campaign, to strengthen collaboration between dental and pharmacy teams.

Opticians Working with the Local Eye Health Network Chair: Email a poster(s) from the Starting Well Core resource pack (see section 6.2) to optometry services in your region, requesting they display it in their waiting rooms to promote a Dental Check by One. They may also be able to add the image to digital or social media feeds and profiles. To support signposting and referrals, supply local optometry services with a list of local dental practices who are participating in Starting Well Core and accepting new child patients. There may be opportunities for optometry teams to refer children or contact participating practices directly to support families/carers book appointments (e.g. via secure NHS.net email accounts).

Communications teams and stakeholders as required

Working with local communications teams and stakeholders as required: Share the Starting Well Core resource pack (see section 6.2) as appropriate in your region. Develop a leaflet or webpage with public-facing information about which dental practices are readily accepting child patients. Promote a Dental Check by One via social media. This could also be linked with wider activity for other children’s health campaigns, local Early Years programmes, World Oral Health Day or National Smile Month. Develop a toolkit for dental, health and social care and Early Years services in your region. This may include information on Starting Well Core; select resources to promote as hand-outs, digitally or via social media; lines for newsletters or bulletins; sample tweets or images for social media (Alternatively, incorporate these components into other local children’s health toolkits). The toolkit theme could vary across different months e.g. breastfeeding, weaning, healthy eating, toothbrushing.

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Stakeholder / setting

Suggested activities

Develop local promotional resources E.g. Record video interviews of local GPs, Health Visitors and dental teams who recognise the importance of children’s oral health. These could be used on websites, social media or in waiting room video reels.

Local events, stalls and stands

Dental teams from practices participating in Starting Well Core may be willing to run a stand at a local carnival, fete or festival to promote dental attendance and build rapport with the local community. There may also be opportunities for stands or stalls in community settings such as shopping centres, libraries and places of worship. Use local events, stalls and stands as opportunities to hand out oral health promotional materials to the public (e.g. toothpaste, stickers, information leaflets).